Who is a good doctor?

Who is a good doctor?

Vijay Gopichandran

I am writing this blog following three days of intense discussions and deliberations on medical ethics. The annual meeting of the working editors of the Indian Journal of Medical Ethics just got over. This year, just before the annual meeting of working editors, the Forum for Medical Ethics Society had organized a one-day intensive workshop on Indian Philosophical traditions. One message during that workshop, by the facilitator Prof. Meera Baindur, was particularly impressive to me. She discussed the difference between doing good things versus being a good person. While the former is an aspect of ‘karma’ of a person, the latter is the ‘dharma’ that a person follows. I am going to use this karma-dharma difference to analyze medical ethics. The question that I will address is “Who is a good doctor?”

The first point I want to address is, whether a good doctor is one who does what is good for his/her patients. This is largely true. The first tenet of medical ethics is “do good”. The primary intention of a doctor is to do whatever is good for the patient. The second principle is “do no harm”. Looked at superficially, this seems to be a very clear and direct principle of medical ethics. It appears that it is a good dictum to say a good doctor is one who always does good and never does harm.

However, this can be problematic at times. There are can be instances where a doctor inadvertently causes harm. The doctor may sometimes make a genuine mistake. So is this doctor who makes the unintentional mistake, bad? If we say we can pardon a doctor who makes a mistake, how many mistakes can we pardon? Would our stand be different if the doctor commits the same mistake again and again? These situations increase the complexity of the goodness of a doctor. The other aspect is when a doctor intentionally does certain harms in order to ultimately benefit the patient. For example, the doctor may have to do a painful incision of an infected abscess to drain the pus. The procedure may be extremely painful, but ultimately the intention is to cause relief. Is this kind of harm permissible? If such harm is permissible, is it alright to operate on a patient for a hernia or hydrocoele without giving anaesthesia? Ultimately the goal is to relieve the hernia or hydrocoele by performing surgery. So what if anesthesia is not given? Is it alright to kill a patient, and do the highest form of harm, in case the patient is a terrorist with a plan to destroy many lives? Would that count as harm, as by killing this one terrorist, the doctor will be saving several lives?

Linking the definition of a “good doctor” to his or her actions, therefore, is a bit problematic. The morality of an action is strongly influenced by the circumstances. I was once faced by a major ethical conflict when I was practicing in a rural NGO in Kancheepuram. A young man was brought to the clinic with severe abdominal pain. On examination it appeared that he might have a dangerous condition in the abdomen, probably a perforation of the appendix, leading to a severe life-threatening condition. My medical training told me that I had to stabilize him by providing first aid and rapidly transfer him to a tertiary care center where surgery may be performed to save his life. But the family of this young man, who all belonged to a marginalized tribal community, with bad experiences of ill-treatment and abuse in the tertiary care hospital, refused to take him there. They insisted on letting him go home. I had no choice but to let him go home as all my efforts to convince him and his family failed. My ethical conflict was that I was obviously causing harm to this young man and endangering his life, by sending him home. I was extremely guilt-ridden for several days. I kept running the various possibilities through my mind. I kept asking myself what else could I have done. One question that haunted me those days, and often clouds the mind of many young doctors is, “am I a good doctor?”. Then I wrote about this case study in the Indian Journal of Medical Ethics. I was overwhelmed when Dr. Roopa Devadasan, a fellow physician, who has worked extensively with marginalized tribal communities, and who currently has completely dedicated her time and work in improving and providing school education, wrote a brilliant commentary in response to the case study. I was humbled to read that I was not alone in this world making these strange, bizarre, out of text-book, seemingly harmful decisions. She had shared her experiences of trying to help tribal women go to hospitals for delivery and narrated how she had faced similar moral conflicts. It was later that I came across and read the works of other illustrious physicians in all the remote rural areas of the country, and how they all have either asked themselves or have been asked by others whether they are good doctors. Some of their actions in resource-limited settings can be viewed as harmful. For example, some are forced to use inferior medicines because of resource constraints, when a better but more expensive option is available.  But these doctors are all amazing human beings who have completely dedicated their lives to the work in communities. Are they “good doctors”?

In this context, Dr. Meera Baindur’s comment struck me with a lot of force and meaning. What if “good doctor” is about being good rather than doing good? What if the goodness is related to the dharma of the doctor? Rather than evaluating the ethics of a doctor by what he or she does, could we evaluate them on their ‘being a good doctor’? Being a good doctor would involve a whole lot of things more than just their actions. The theory of action states that every action begins as a thought, then it is processed, planned, and then converted to action. Repeated actions become habits. Habits that are motivated in response to the environment become behaviors. And the sum total of thoughts, actions, habits, and behaviors comprise “being a good doctor”. So, rather than judging a doctor as good or bad merely based on their actions, why not evaluate them based on “being a good doctor” which is thoughts, intentions, motivations, inspirations, attitudes, actions, habits and behaviors, everything rolled into one? Would this help me address the moral conflict that I described previously?

I sent the young man home, despite knowing that he needed emergency surgery and otherwise he would die. My thoughts were not to cause harm to this young man. I tried my level best to convince the family to take him to the hospital, but my efforts failed. So my intentions and thoughts were good. When I had to finally make a decision to send him home, I made sure that I accompanied him home to ensure that I could start an intravenous fluid at home and make sure that he is closely monitored. I thought maybe they may change their mind at a later point in time. So I did follow up and provide the best option within the constraints that I faced. I spoke about it, reflected on it, discussed this with my seniors and colleagues, wrote about it and created a discourse on difficult decisions that a young doctor may have to make in resource-limited settings. These all also indicate praxis and an attempt to learn, improve and share knowledge. The whole set of actions, when viewed in this larger picture, helped me see that I am “being a good doctor”.

In the Mahabharata when Draupadi is molested in the court of Hastinapura, she asks an important question to all the senior people sitting in the court as mute spectators. “What is the dharma of the king, who lost me in the gamble?” To this nobody in the court has an answer. Bhishma says, “I cannot answer your question, as the matter of Dharma is very subtle”. This answer points out the complexity of assessing the right Dharma for a person. In the Indian Philosophical traditions, Dharma does not emerge from the Gods. Dharma is not codified in the Vedas, as there are various inconsistencies in them. Nor do great sages and saints agree on their opinions on Dharma. Kalidasa, the Sanskrit poet of fifth century AD says, “the true Dharma lies in the heart of the good person”. Therefore, the Indian classical traditions place great value in being good and when a person is good, then their decisions and actions are good.

I strongly believe now that actions are not enough as indicators of a good doctor. On the other hand, being a good doctor helps do the right thing. The aim of medical ethics is to help doctors be good, and not just do good. The process of becoming good is a matter of disciplining the mind to see a cause larger than oneself in the practice of medicine, respect each individual as an end in themselves, develop a habit of moral reflection in all decisions and actions, and inculcate a high sense of integrity in thoughts, words, and actions. Yes, learning medical ethics as a subject in medical colleges may be important, but medical ethics do not come from a vacuum. Medical ethics comes in the background of moral values and the process of “being good”.